Psychic Orthopedics in Haiti

Orthopedic surgeons are tasked with repairing the architecture of our bodies, setting bones straight when they break and correcting injuries to muscles and joints. It doesn’t take a medical degree to know that, most of the time, those structures lie inside the skin. That means that one of the most important tools available to a modern orthopedic surgeon is the X-ray machine, allowing the surgeon to see the problem and form a plan of action before the patient is on the surgical table.

So how does an orthopedic surgeon work in a tent hospital on the border between Haiti and the Dominican Republic, where the best X-ray device available is one normally used for dogs? You practice “psychic orthopedics,” said Rex Haydon, assistant professor of surgery at the University of Chicago Medical Center. Haydon was one of three surgeons who spoke about the challenges and rewards of aiding medical relief in Haiti in a special session of the Department of Surgery Grand Rounds early Wednesday morning.

Grand Rounds typically feature a physician telling the story of an interesting or unusual patient case, illustrated with X-rays, MRIs and vital signs. I’m guessing this week’s session was the only one this year to feature pictures of collapsed buildings and shower facilities constructed from tarps and buckets. Speaking in order of their time spent in the field hospital established in Fond Parisien, Haiti, Haydon, Kris Alden and Christopher Sullivan each spent more time detailing the unique experience of practicing orthopedic surgery (often without the actual surgery part) in hot, stuffy tents rather than the gritty details of individual cases. Through the three mini-talks, a story formed of how conditions in the camp changed and improved in the weeks following the January earthquake. But there were also common threads through each of the three surgeons’ experiences that depicted the difficulties of providing modern care in a less than modern setting.

1. X-ray machines

By far the biggest obstacle appeared to be the inability to obtain the reliable, high-quality internal images that orthopedic surgeons are accustomed to consulting in hospitals. The site where the field hospital was built, the Love A Child Orphanage, did have a pediatric clinic with a small, non-portable X-ray unit, but it was logistically difficult to transport injured patients from the camp to the clinic. So the next best option was a hand-held veterinary X-ray device, resembling a laser gun you might see in a Flash Gordon serial. This X-ray gun worked most of the time, but only provided low-resolution, circular images like the one on the right – far from the quality images a state-of-the-art machine provides.

Fortunately, the second team brought with them just such a state-of-the-art X-ray machine, a Philips device that allowed the camp to set up a radiology tent. Unfortunately, that luxury was only temporary, as either the intense heat inside the tent or a power supply mismatch caused the device to break down during the third team’s stay. So it was back to the gun – not ideal, but better than nothing. “It was not optimal, but it was the only game in town,” said Sullivan, an assistant professor of surgery at Comer Children’s Hospital. “Without that, we were blind.”

2. Lack of medical records

The lack of imaging compounded a much more low-tech issue with patients arriving at the camp from other locations – a lack of anything resembling proper medical records. Doctors had to rely on handwritten notes, sometimes written directly on the patient’s cast, to figure out what was the original injury and what procedure the patient may have undergone at the original site. Over time, as the number of volunteers and interpreters in camp grew, more reliable records for each patient was established – written on cardboard sheets.

3. Operating Room Tents

Most surgeries at the camp were conducted by surgeons from Operation Smile, a non-profit group that was already based in Haiti before the earthquake doing predominantly cleft palate correction procedures. But the UChicago surgeons assisted on procedures to repair fractures, amputate limbs, and improve hastily-placed corrective devices like external fixators. But the conditions for these procedures were not exactly ideal. As anyone who has gone camping in the summertime can attest, tents are not the most ventilated structures. Alden (a surgeon with the UChicago-affiliated Weiss Memorial Hospital) joked that the “operating rooms” were equipped with fans and anair-conditioning unit, “which kept the temperature about 88 to 90 degrees.” Both Alden and Sullivan also joked about how hard it was to get used to an operating table that doesn’t move up and down – “table up” and “table down” being two of the most-heard phrases during a typical surgery. It sounds like a ticky-tack complaint, until you realize the discomfort and pain associated with hunching over patients for several hours a day. Yowch.

But in the end, the less than ideal conditions were marginal compared to the life-changing care that the surgeons were able to provide the nearly 1,000 patients passing through the field hospital. Alden recalled a patient in camp who had his left leg amputated that would ask him everyday when he could receive a prosthetic leg, so that he could return to work and not be a burden on his family. It wasn’t a hopeless request; Sullivan said representatives from a company that makes prosthetics visited the camp during his stay and hoped to have devices for patients in the coming weeks. But Alden said the amputee patient’s logic reinforced for him the value of what medical volunteers were providing to the people of Haiti.

“I went down with the idea we would basically be providing basic orthopedic trauma care to fix broken bones, but really it hit me that we were doing more than providing internal fixation,” Alden said. “It wasn’t so much limb salvage as life salvage.”